Guidelines for male circumcision issued

The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recently issued recommendations saying that adult male circumcision should be recognized internationally as an important intervention to reduce HIV transmission. The recommendations also advise countries with high HIV prevalence and low rates of male circumcision to consider rapidly and dramatically increasing access to this surgical procedure to men at risk of heterosexual transmission of HIV. The organizations released these guidelines following an international consultation with various governments, researchers, human rights advocates, funding agencies, and civil society members that was held from March 6-8 in Switzerland. According to the guidelines, circumcision should now be included broadly as part of a comprehensive strategy to prevent HIV transmission, along with the use of condoms, voluntary counseling and testing services, and the treatment of other sexually transmitted diseases. Many individual countries are also in the process of establishing national guidelines on the introduction of male circumcision programs.

The decision to recommend male circumcision as an HIV prevention tool comes on the heels of the results from three randomized, controlled clinical trials that have shown circumcision can reduce the risk of heterosexual transmission of HIV infection by as much as 60% in men. These trials were conducted in Kisumu, Kenya; Rakai District, Uganda; and Orange Farm, South Africa. Studies to predict the impact of different prevention technologies on the course of the epidemic suggest that implementation of circumcision programs in sub-Saharan Africa could prevent 5.7 million new HIV infections over the next 20 years.

The WHO/UNAIDS guidelines recommend that more research be conducted on how male circumcision may impact HIV transmission to women, as well as the risks and benefits of performing circumcision in men who are already HIV infected. An ongoing study sponsored by the Bill & Melinda Gates Foundation is looking at how male circumcision affects HIV transmission to female partners. Limited data from studies already conducted suggests that HIV transmission between recently circumcised HIV-infected men and their female partners may be increased if they engage in sexual activity before their surgical wound is completely healed, and this process may take longer in HIV-infected men.

One concern shared by WHO/UNAIDS and organizations that will be implementing circumcision programs in developing countries is ensuring access to safe services, which requires training providers to conduct the procedure, providing sanitary settings and properly sanitized instruments, and then closely monitoring and evaluating circumcision programs once they begin to ensure that the circumcisions are being performed properly. The recommendations also suggest that men seeking circumcision be offered counseling services to prevent them from having the false perception that they are completely protected against HIV infection and therefore able to engage in high-risk behaviors, an idea known as behavioral disinhibition.

In Uganda, researchers are planning to establish a limited number of sites to serve as centers of excellence for adult male circumcision. The site in Kisumu where the clinical trial of male circumcision was conducted has received funding from the US President's Emergency Plan for AIDS Relief (PEPFAR) to serve as a center of excellence in the region.